Teaching a Student with Autism and Apraxia Vowel Blends

_______________________
A Project Presented to
the Faculty of the Undergraduate
College of Education
James Madison University
_______________________
in Partial Fulfillment of the Requirements
for the Degree of Bachelor of Science
_______________________
by Victoria Elizabeth Dickens
April 2013

Accepted by the faculty of the Department of Education, James Madison University, in partial fulfillment of the
requirements for the Degree of Bachelor of Science.
FACULTY COMMITTEE:

HONORS PROGRAM APPROVAL:

Project Advisor: Newton, Jen

Barry Falk, Ph.D.,

Director, Honors Program

Reader: Bosch, Carmen

Reader: Lowman, Dianne

Abstract (300 words)

Introduction
Childhood Apraxia of Speech is defined as a developmental speech disorder that affects
the accuracy and consistency of speech production without a lack in neuromuscular deficits
(American Speech-Language-Hearing Association, 2007). This disorder is characterized by
specific oral language difficulties for the student. Many students with apraxia make slow
progress in speech therapy (Moriarty & Gillon, 2006), therefore, this study investigated how
systematic, direct instruction impacted a learners ability to decode and recode words,
specifically consonant and vowel blends.
In special education, there was a belief that students with Autism and apraxia share
common language deficits, possibly alluding to a link between the two disorders, but due to a
study conducted by Shriberg in 2011, that hypothesis is no longer plausible. Though both
students with autism and students with apraxia experience language difficulties, this comparative
study showed that these students struggle with different aspects of language. While students with
apraxia have a slower speech rate, uncommon phoneme distortions, and spatiotemporal vowel
errors, students with autism struggle with inappropriate loudness, pitch, misplaced stress, speech
errors, and repetitions or revisions. For the student in this study, multiple errors from both
apraxia and autism were present in his speech.
In the field of special education the research regarding autism and apraxia language
instruction is sparse, therefore all studies in regards to this subject were pertinent to this study.
This researcher sought to investigate systematic instruction of letter-sound correspondence
taught through direct instruction for a second-grader with apraxia and autism. The student
This paper will present a literature review, the research design of this specific study, an
analysis, and conclusions about this study.

Literature Review
Apraxia, sometimes referred to as Childhood Apraxia of Speech or CAS, is a
developmental speech disorder that affects the accuracy and consistency of speech production in
the absence of neuromuscular deficits (American Speech-Language-Hearing Association, 2007).
Inconsistent speech errors, sound-sequencing difficulty, vowel errors, articulatory groping, and
prosodic disturbances are common speech characteristics in children with CAS (Davis et al.,
1998). Some examples of these speech errors would be jumbling the order or consonant blends,
such as pronouncing split as /s/ /l/ /p/ /i/ /t/ and there may be articulator groping as the student
stumbles, pauses, and blends some phonemes incorrectly. One major deficit may be vowel blends
such as /ou/ pronounced as /o/ /u/ instead of the student realizing that the two present together
create a new phoneme than the two letter separately. In addition to these verbal challenges,
students with CAS also struggle with phonological awareness and written language disorder, as
well as receptive and expressive language impairment. Some professionals still argue over the
cause, the manifestation, and the appropriate approach to teaching children with apraxia, and
some experts grapple with the precise definition of apraxia and the best measures to diagnose a
child with apraxia.
Many pedagogical difficulties face teachers with students who have childhood Apraxia of
speech due to the common characteristics of children with apraxia. Children with CAS require
81% more therapy than children with phonological impairment to produce a functional change in
speech production (Moriarty & Gillon, 2006), and a lot of interventions concentrate on motoricbased imitation techniques which proved ineffective outside of a small number of case studies.
Despite the lack of response to speech therapy, many educators concentrate on oro-motor
training and pathology techniques because the majority of existing interventions have been

developed from the theoretical premise of CAS as a deficit in prearticulatory sequencing of the
speech mechanism (Moriarty & Gillon, 2006).
Statistically students with CAS are more likely than other children with other speechlanguage disorders to experience written language deficits (Lewis et al,. 2004), yet few
interventions have strongly encouraged students to work on skills that would remediate this
deficit. For reasons unknown CAS impacts student learning more than other speech disorders,
and these deficits are more pervasive and elusive than characteristics of other speech disorders.
This proves that the need for research and interventions for children with CAS is high, yet the
response in the field to this need remains low.
Few interventions have been developed or studied for childhood apraxia of speech and
the findings from the studies may not specifically support any given hypothesis due to student
variability and the motivational factors involved in the intervention sessions. The most effective
interventions have been interventions that emphasize phonological awareness, reading, spelling,
and segmenting and blending words within the intervention sessions.
In 2006 Moriarty & Gillon conducted a study in order to test the hypothesis that
integrated phonological awareness intervention improved speech production, phonological
awareness, and decoding skills for children with childhood apraxia of speech. In this study, 3
children who spoke New Zealand English (ages 6 years 3 months, 7 years, 3 months, and 6 years
10 months), received an intense integrated phonological awareness intervention. The
pseudonyms Derek, Katie, and Paul are used to represent the three students in the study. These
children were chosen out of ten students who were referred by speech-language therapists, and
the students could not have any hearing, visual, or neurological disorders in addition to CAS to
eliminate variability of the intervention on CAS in particular. They were administered a battery

of tests, and for all three subjects sequencing errors were present in pronouncing vowels
correctly, consonants were skipped, there was evidence for reduced DDK sequencing, the
students displayed poor phonotactics, and received an age equivalency of 4-4.5 years old (in
language skills). These characteristics reveal CAS tendencies in Paul, Derek and Katie,
confirming the diagnosis of CAS. Once the students were selected, the study utilized a multiple
single-subject design with repeated measures; each child received intervention for three 45
minute sessions for 3 weeks, adding up to 7 hours of individual treatment for each student. Each
session included identifying phonemes in isolation, identifying initial and final phonemes in
words, phoneme segmentation and phoneme blending, and phoneme manipulation with
grapheme blocks. The researcher used immediate error correction to point out mistakes without
delay after the student made a mistake, then gave the student a chance to follow the correct
model and retry the probe. Each student received intense supports that targeted areas of weakness
shown in the assessments given; each speech probe compiled 12 target words and 12 control
words based on the processes for improvement. In addition to speech probes, each student
received phoneme segmentation probes and phoneme manipulation probes. The phoneme
segmentation probes consisted of ten stimulus words taken from the childs target speech
production words, which the student had to segment into individual phonemes using colored
blocks. During the phoneme manipulation probes each child manipulated letter tiles to
demonstrate sound changes within a word. Two participants showed significantly improved
target speech and phonological skills during intervention, and they generalized the phonological
skills from trained items to untrained items and transferred newly acquired knowledge to
improve performance on non word reading tasks. In the areas of speech production, Derek
improved from 56% at baseline to 92% post-intervention, but there was no improvement in his

target control speech production measures. Katie demonstrated a significant improvement in

target speech production measures from 63% at baseline to 100% post-intervention, and she
improved from 58% to 65% in her controlled speech production measures (Moriarty & Gillon,
2006). Paul demonstrated no significant improvement in targeted speech production measures
with a PPC of 25% at baseline and 34% post-intervention, and there was little improvement for
control speech production measures. In the area of phonological awareness, Derek and Katie
demonstrated significant improvement in phoneme segmentation (Moriarty & Gillon, 2006). The
students transferred the improved phoneme segmentation skills to untrained items, and improved
their phoneme manipulation performance 71.1-percentage points for Derek and 35 percentage
points for Katie. Paul significantly improved his phoneme segmentation from 0 to 20% but he
did not transfer phoneme segmentation to untrained items. Finally for non-word reading and
letter sound knowledge Derek improved by 25% and he improved his non word reading score by
48% while Katie improved her non-word reading a letter sound knowledge by 15% and her nonword reading score by 22.4%. Paul reached a ceiling on his four trained letter-sound
combinations but showed no improvement between the pre- and post-intervention measures
(Moriarty & Gillon, 2006). These mixed findings show varied support for the hypothesis that the
integrated phonological awareness intervention would increase the speech production skills of
students with CAS; two subjects significantly improved accuracy while one subject did not
significantly improve his performance for the targeted productions (Moriarty & Gillon 2006).
Derek and Katies progress also support the second hypothesis that an integrated phonemic
awareness intervention would increase phoneme awareness skills. The third hypothesis, which
stated that an integrated phoneme awareness intervention would enable participants to use
phoneme awareness and letter-sound skills gained in the intervention to improve decoding

performance, was supported by the performance of Derek and Katie. If the treatment is intense,
this intervention can increase target speech production, phonemic awareness, and improve
decoding in children with CAS.
Experts disagree on the definition and diagnosis of CAS; some experts define apraxia as a
rare neurological, sensorimotor speech sound disorder (American Speech-Language-Hearing
Association, 2007) while other sources define apraxia as a motoric impairment (Moriarty &
Gillon, 2006). In order to diagnose a student and therefore attain the services needed and
research any interventions that may help that student, these professionals need to reach a
consensus and implement one definition for diagnosis and any misconceptions should be noted
and dispelled via literature, training, and informative studies.
Teachers should provide more intense, individualized practice for students with CAS in
order to target and correct student speech errors and in order to teach the student grapheme and
phoneme connections. All of the studies analyzed show that children with CAS respond quite
differently to intervention, proving that interventions need to be tailored to the needs of the child
to target that students particular area of weakness. The frequency of producing sounds and
interventions that concentrated on phoneme-grapheme association are beneficial to students with
apraxia, as well as reinforcing activities that involve decoding and recoding words. These studies
also support the idea that motivation is a key factor when implementing an intervention (Strand,
et al, 2006). Motivated students who work hard and get rewards not only retain the information,
but also generalize the information to other untrained areas.
In all of these studies students did not respond as well to oro-motor therapy in
comparison to methods that incorporated direct instruction or modeling. Speech therapy, in
several cases, proved less effective than the interventions; this leads to a dilemma. Many special

educators turn to speech therapy in order to remediate for students with CAS, yet these studies
show that speech therapy is less effective than direct instruction in how to read words. If speech
therapy concentrates on correct pronunciation and speech therapy is less effective, then the
problem does not lie in the students ability to make the target sound; the student should spend
less time getting speech therapy and more time receiving an intervention, where the exact
deficits in letter-sound correspondence knowledge is addressed.
Slow progress in therapy is associated with this disorder yet there are few empirical
studies for interventions (Moriarty & Gillon, 2006). There are far too few studies describing
interventions for Apraxia; professionals need more research to effectively teach students with
CAS. Sample sizes in studies are small and the results for some studies are debatable
inconclusive or not useful for a teacher trying to plan interventions for a student with CAS.
While most of these studies show what interventions are effective and which interventions
showed no significant improvements, each intervention could only be conducted on a small
sample; not only are there few studies, but these studies are mostly case studies and small sample
sizes in comparison to the population of children with childhood apraxia of speech. The
interventions already conducted should be re-implemented on multiple subjects in order to verify
the results of previous studies. More research needs to be conducted using different interventions
so teachers and speech pathologists can implement the best possible practices for students with
childhood apraxia of speech.
Though some studies attempt to identify similarities in the speech difficulties seen in
children with autism and children with CAS, the double disassociations in speech, prosody, and
voice impairments in ASD were interpreted as consistent with a speech attunement framework,
rather than with the motor speech impairments that define CAS (Shriberg, et al, 2011).

How do these interventions need modifications to accommodate for autism? Theory that the two
are comorbid has been disproved, but some educators think that both lack praxis deficits, causing
difficulties in reading (Shriberg, et al., 2011). However, for students who have autism and
apraxia, reading interventions need strong behavioral supports, positive reinforcement, and focus
on the language deficits associated with both disorders.
Research Design
This study followed a single case study format where baseline data was collected using
the DIBELS and the Letter-Sound Accuracy Assessment before selecting an appropriate
intervention. During the intervention sessions, data was collected periodically using the DIBELS
and the Letter-Sound Accuracy Assessment to track the progress made by the student due to the
intervention. The operational measures confirmed that the subjects deficit resided in the
consonant and vowel blends, and a few of the more obscure letters. Each intervention period
would consist of phoneme grapheme rehearsal; there would be 6 to 8 graphemes, and when the
teacher pointed to the grapheme, the student would pronounce the sound associated with the
letter. The teacher prompted the student three times for each letter in random order, and new
letters were introduced systematically in each lesson. The letters were chosen based upon the
letter sound accuracy measures given, and then measured for mastery during each lesson. If the
student did not give the correct answer for the probe, the teacher would reteach that letter sound
with the My-Turn, Together, Your-Turn Method of direct instruction. New sounds were
introduced during the lesson before the student would encounter the probes, and then the new
sounds would be tested for mastery. The student learned many new sounds, and even progressed
to vowel blends and consonant blends during this probe time.

After the student would read vocabulary words on flash cards; the student would decode
and recode the word using dots and arrows to help him track and pronounce each sound in the
word. As the student tracked the sounds with the dots the student would decode the word, then
the student would run his finger along an arrow under the dots from left to right and recode the
phonemes into one cohesive word. Many of the words were decodable words from the decodable
text that he read next; he would read the book with immediate error corrections and
comprehension questions after the reading. Once he would reach the objective for the decodable
passage, he would move up to the next higher-level book in the decodable book series, and he
would have new sight words linked to the text.
Analysis
Throughout the study, attending behaviors proved problematic so a system of positive
reinforcements and specific praise were implemented in order to increase the students attention
to the task. The student enjoyed playing Temple Run, Studio, and Cars on an iPad, so there were
two brain breaks at the middle and the end of each 45 minute intervention session. These
sessions were called brain breaks, but he could lose a brain break if he got 5 slash marks by brain
break on the schedule for not responding or inappropriate behaviors. On the far side of the
schedule, there was a column for stickers. When Kevin got to ten stickers, he would receive a
prize car for working hard that day. Each sticker was given with specific praise for good
behaviors such as correct decoding (without a prompt), correct pronunciations, responsiveness,
remaining in his seat, and for attending to a task for long periods.

Conclusions

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Children with CAS benefit from specific interventions that use direct instruction to teach
the sounds of individual letters and vowel blends. This student responded positively to the
interventions implemented throughout the study. His DIBELS score for the Nonsense Word
Fluency assessment increased and his score on the letter sound accuracy assessment, especially
on the sounds that were targeted during the interventions. The subject seemed to respond better
to the letter sound correspondence intervention than the comprehension intervention

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